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Cole Eye Institute

Case Discussion:  RVO and CSCCase Discussion:  RVO and CSC

Justis P. Ehlers, MDAssistant ProfessorOphthalmic Imaging CenterCole Eye InstituteCleveland Clinic Foundation

Cole Eye Institute

• Bioptigen (P)

• Thrombogenics (C,S,R)

• Regeneron (S)

• Genentech (R)

• Synergetics (P)

Financial Disclosures

Cole Eye Institute

• Bevacizumab (RVO/CSR)

• Ranibizumab (CSR)

• Eplerenone

• Triamcinolone

• Rifampin

• Photodynamic therapy

Off‐label discussion

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Learning Objectives

• Provide a case‐based approach to discussing diagnostic and therapeuctic approach to retinal venous occlusive (RVO) and central serous retinopathy (CSR)

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Case 1: 43 y/o male presents with sudden vision loss while jogging

VA 20/400

Diagnosis?Additional Diagnostic Testing?

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VA 20/400

Work-up?Treat? If yes, treatment approach?

Case 1

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VA 20/20 after anti-VEGF x 3VA 20/25 after anti-VEGF x 1

Treatment frequency and regimen?

Case 1

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Case 2: 78 y/o female referred for NVG and CRVO. Scheduled for tube.

VA: CF @ 4 ftIOP: 38

Management Options?

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Case 2

s/p bevacizumab x 1 and PRPVA: 20/80IOP: 19

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Case 2

s/p bevacizumab x 2VA: 20/60

s/p bevacizumab x 3VA: 20/50

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Case 2

s/p bevacizumab x 4VA: 20/70

s/p bevacizumab x 5VA: 20/200

Tachyphylaxis?Progressive ischemia?VMT-related?Next steps?

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Case 2

PRP # 2 and bevacizumab #6

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Case 2

Overlay: OCT Fundus Overlay: ILM-RPE DifferenceTransparency: 0 % Transparency: 0 %

Extracted B-Scan

s/p bevacizumab x 6s/p PRP x 2VA: 20/60

Additional treatment?

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Case 2Fovea: 257, 60Fovea: 257, 60

Overlay: OCT Fundus Overlay: ILM-RPE DifferenceTransparency: 0 % Transparency: 0 %

Extracted B-Scan

s/p bevacizumab x 7VA: 20/200

Options?Higher dose?Higher frequency?Switch agents?

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Case 2Fovea: 273, 65Fovea: 273, 65

Overlay: OCT Fundus Overlay: ILM-RPE DifferenceTransparency: 0 % Transparency: 0 %

Extracted B-Scan

s/p ranibizumab x 1VA: 20/80

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Case 2Fovea: 245, 64Fovea: 245, 64

Overlay: OCT Fundus Overlay: ILM-RPE DifferenceTransparency: 0 % Transparency: 0 %

Extracted B-Scan

s/p ranibizumab x 24 week intervalVA: 20/200

Tachyphylaxis? Progressive ischemia?Options?Maintain therapy? Switch?

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Case 2Fovea: Fovea not foundFovea: Fovea not found

Overlay: OCT Fundus Overlay: ILM-RPE DifferenceTransparency: 0 % Transparency: 0 %

Extracted B-Scan

s/p aflibercept x 14 week intervalVA: 20/60

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Case 2

s/p aflibercept x 134-5 week intervalVA: 20/40

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Case 3: 54 y/o male presents with sudden vision loss

VA 20/200

Treatment choice?

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Case 3

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Case 3

s/p anti-VEGF x 3 4-6 week intervalVA: 20/20

Treat or observe? Follow-up?

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Case 3

Following observationVA: 20/50Next Step?

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Case 3

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Case 3

Helpful?Treatment?

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Case 4

38 y/o male c/o inferotemporal scotoma x 3 days

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Case 4

Diagnosis?Treatment?

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Case 4

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Case 5• 65 year old patient with decreased vision OU

• 3/15/2012:

VA (OD): 20/50 VA (OS): 20/400

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Case 5 

Fluorescein angiogram

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Case 5 

Fluorescein angiogram

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Case 5

ICG

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Case 5

ICG

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Management Options?

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Case #5

• One month after Avastin OS and observation OD

– VA (OD):  20/50

– VA (OS):  20/500 

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Case #5

• OS:  total of 7 Avastin injections OS, little change with injections

• OD:  Worsening SRF, stable vision

• Patient begins eplerenone 25 mg qd on 11/07/2012 (about 8 months since initial visit date)

VA (OD): 20/50 +1 VA (OS): 20/250

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Case 5

Baseline at Initiation ofeplerenone

Month 1

Month 3*patient begins 50 mg

Month 6

VA (OD): 20/50 +1

VA (OD): 20/40 -1

VA (OD): 20/30 -2

VA (OD): 20/20

VA (OS): 20/250

VA (OS): 20/200

VA (OS): 20/150

VA (OS): 20/150

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43 year old female referred for second opinion on CSR OS

POHVision decreased OS 11/2011Dx with CSR 2/2012 Treated with ranibizumab one month ago

PMHUrinary frequency

MedsCelexa 20 mg

Exam: VA 20/20 20/100 ph 20/40+1.25 20/20

Case 6

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Case 6

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• Presentation MRx 20/20

Case 6

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Case 6

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Case 6

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Case 6

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• Diagnosis?

• Management plan?

Case 6

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• Two months later: Improved, VA 20/20

Case 6

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• 2 months later: VA 20/30

Case 6

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• 2 months later: VA 20/30

Case 6

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• 2 months later: VA 20/30

Case 6

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Case 6

• 1.80mm x 6.00mm x 4.70mm.

• Too small for differentiation, however lesion is avascular, and highly reflective - which is not consistent with MM

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• Lost to follow-up

• 6 months later

• VA: 20/100

Case 6

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• Looking again at baseline:

Case 6

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Case 6

• 3.5 mm in height x 10.5 mm anterior to posterior x 8.0 mm laterally

• Low to medium internal reflectivity

• Referred for plaque radiotherapy vsenucleation

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Thank You